Mark Fenton, Scott McIntosh, Eduardo Simoes, Jody Stones

There are several recommended approaches to implementing environmental and policy changes in communities. An assessment needs to be done of the facilities, programs and policies in place for community, worksites, schools and the medical community for a baseline analysis of a starting point to implement change. An advisory group or coalition needs to analyze the data and design strategies to address the gaps and barriers in support for cardiovascular health promotion.

Individual behavior change has been the focus of many efforts to reduce the population level risks for cardiovascular disease, using a "three-legged stool" of intervention: smoking prevention/cessation, improved nutrition, and physical activity promotion. However, successes in reducing tobacco use suggest that policy and environmental initiatives-not just individually targeted efforts will be crucial to long-term success. For example, public place smoking bans, official public health statements, mass media campaigns, advertising restrictions, and tax policy all appear to have had positive effects. Analogous efforts to promote physical activity should include policies which will encourage routine walking and bicycling. These include architectural guidelines (e.g., prominent and inviting stairwells and bicycle parking, lockers and showers at work sites), improved transportation networks (safe continuous bike and pedestrian routes, continuity with mass transit), and efficient land use policies (dense, diverse zoning with plentiful walking/bicycling destinations and recreation space). All appear to increase routine walking, for example, whether simply flights of stairs climbed or the household share of walking trips for transportation.

A recommended approach to such initiatives is the creation of an interdisciplinary state-level coalition of all the affected sectors, including but not limited to transportation and planning, education, parks and recreation, public safety, health care providers and insurers, advocacy groups, and the private sector. A plan should be jointly created and implemented, not imposed on this group. Through the process, surveillance must be a priority and natural experiments should be sought (for example, matched communities which will and will not build a bike trail or implement walk-to-school policies) so that impact evaluations may be made over time.